mock scenario tonsillectomy

V3

Mock Scenario Tonsillectomy

We have developed this scenario to provide an outline of the performance we expect and the criteria that the test of competence will assess.

The Code outlines the professional standards of practice and behaviour which sets out the expected performance and standards that are assessed through the test of competence.

The Code is structured around four themes – prioritise people, practise effectively, preserve safety and promote professionalism and trust. These statements are explained below as the expected performance and criteria. The criteria must be used to promote the standards of proficiency in respect of knowledge, skills and attributes. They have been designed to be applied across all fields of nursing practice, irrespective of the clinical setting and should be applied to the care needs of all patients.

Please note - this is a mock OSCE example for education and training purposes only.

The marking criteria and expected performance only applies to this mock scenario. They provide a guide to the level of performance we expect in relation to nursing care, knowledge and attitude. Other scenarios will have different assessment criteria appropriate to the scenario.

Evidence for the expected performance criteria can be found in the reading list and related publications on the learning platform.

V3

Theme from the Code Expected Performance and Criteria

Promote professionalism

Behaves in a professional manner respecting others and adopting non-discriminatory behaviour. Demonstrates professionalism through practice. Upholds the patient’s dignity and privacy.

Prioritise people

Introduces self to the patient at every contact.

Actively listens to the patients and provides information and clarity.

Treats each patient as an individual showing compassion and care during all interactions. Displays compassion, empathy and concern. Takes an interest in the patient.

Respects and upholds people’s human rights. Upholds respect by valuing the patient’s opinions and being sensitive to feelings and/or appreciating any differences in culture.

Checks that patient is comfortable, respecting the patient’s dignity and privacy.

Infection prevention and control

Adopts infection control procedures to prevent healthcare-associated Infections at every patient contact.

Applies appropriate Personal Protective Equipment (PPE) as indicated by the nursing procedure in accordance with the guidelines to prevent healthcare associated infections.

Disposes of waste correctly and safely.

Care, compassion and communication

Seeks patient’s permission/consent to carry out observations/procedures at every patient contact.

Checks patient identity correctly both verbally, and/or with identification bracelet and the respective documentation at every patient contact.

Uses a range of verbal and nonverbal communication methods. Displays good verbal communication skills by appropriate language use, some listening skills, paraphrasing, and appropriate use of tone, volume and inflection. Good non-verbal communication including elements relating to position (height and patient distance), eye contact and appropriate touch if necessary.

V3

Practice effectively Maintains the knowledge and skills needed for safe and effective practice in all areas of clinical practice.

Organisational aspects of care specific to specific skills

Ensures people’s physical, social and psychological needs are assessed.

Completes physiological observations accurately and safely for the required time using the correct technique and equipment.

Ensures any information or advice given is evidence based including using any healthcare products or services.

Documentation

Documents all nursing procedures accurately and in full, including signature, date and time.

Writes patient’s full name and hospital number clearly so that it can be easily read by others.

Records the date, month and year of all observations.

Charts all observations accurately.

Scores out all errors with a single line. Additions are dated, timed and signed.

Writes the record in ink.

Preserve safety Supplies, dispenses or administers medicines within the limits of training, competence, the law, the NMC and other relevant policies, guidance and regulations. Medicine management

The Mock OSCE is made up of four stations: assessment, planning, implementation and evaluation. Each station will last approximately fifteen minutes and is scenario based. The instructions and available resources are provided for each station, along with the specific timing.

V3

Scenario Sam Evans has been admitted to the Surgical Ward for an elective Tonsillectomy today and is accompanied by a carer. You will be asked to complete the following activities to provide high quality, individualised nursing care for the patient, providing an assessment of her needs using a model of nursing that is based on the activities of living. All four of the stages in the nursing process will be continuous and will link with each other. Station You will be given the following resources

Assessment – 15 minutes You will collect, organise and document admission information about the patient.

• Assessment overview and documentation (pages 9-11)

• Wong-Baker Faces Pain Rating scale (ticked) (page 24)

Planning – 15 minutes You will complete the planning template to establish how the care needs of the patient will be met, how these are prioritised and what evidence-based nursing care you’ll provide.

• A partially completed nursing care plan for two nursing care and self-care needs (pages 12-15)

• A blank National Early Warning score chart 2 (PEWS2) (page 23)

Implementation – 15 minutes You will administer medications while continuously assessing the individual’s current health status.

• An overview and Medication Administration Record (MAR) (pages 16-19)

• Wong-Baker Faces Pain Rating scale (ticked) (page 24)

Evaluation – 15 minutes You will document the care that has been provided so that this is communicated with other healthcare professionals, provide a record of clinical actions completed, disseminate information and demonstrate the order of events relating to individual care.

• An overview and transfer of care letter for admission to a discharge lounge (pages 20-22)

• A blank National Early Warning score chart 2 (NEWS2) (page 23)

On the following page, we have outlined the expected standard of clinical performance and criteria. This marking matrix is there to guide you on the level of knowledge, skills and attitude we expect you to demonstrate at each station.

V3

Assessment Criteria

Introduce self to child and carer

Explain to the child and family the purpose and format of the assessment process and gain consent

Determine the relationship of the adult present to the child

What is the family composition? Who lives at home with the child? Do they have siblings? If so, what are their names and ages.

May establish who has parental responsibility for the child

Establish what the child likes to be called

Be welcoming in a warm, friendly fashion

Maintain good eye contact throughout

Use jargon-free, non-technical terms throughout

Encourage the child and family to ask questions and voice any concerns. Use a mixture of open and closed questions

May ask what the child and family's first language is? If it is not spoken English, do they need an interpreter or 'signer' to be present?

Demonstrate respect for the child's gender, cultural and religious beliefs throughout the assessment

Clarify understanding of issues raised by reflecting back the child's and parent's statements, such as 'What happens when your child eats peanuts?'

May check the height and weight recorded for the child with the child or parent

Find out what the child and family's reason for attending the hospital or clinic is

Ask the child and family to describe the symptoms of the illness or problem in their own words

Has the child been in hospital before? If so, when was this and what was wrong with them?

May check for allergies

V3

What medicines is the child currently taking? (Note the dosage and frequency of all medicines)

Has the child been immunised? (If so, take details of which vaccinations they have received and when. Check this against the current recommended immunisation schedule. Make a note of any vaccinations they have not received and the reason why.)

Accurately complete the admission documentation.

Planning Criteria

Handwriting is clear and legible for problems one and two

Identify two relevant nursing problems / needs

Identify aims for both problems

Set appropriate evaluation date for both problems

Ensure nursing interventions are current / relate to EBP / best practice

Self-care opportunities identified and relevant

Professional terminology used in care planning

Confusing abbreviations avoided

Ensure strike-through errors retain legibility

Print, sign and date

Implementation Criteria

Clean hands with alcohol hand rub, or wash with soap and water, and dry with paper towels

Introduce self to child and parent

V3

Check that the name and either date of birth or hospital number on the medication chart corresponds with the details on the child's name band and checks this verbally with the child or parent

May identify if the child has any previous experience of taking medication and if so, what the experience was like

Check the child does not have any known allergy or contra-indication to the prescribed medication (if the child does, do not give the medication and inform the responsible prescriber immediately)

Before administering any prescribed drug, look at the person's prescription chart and check the following is correct:

Person

Drug

Calculation of dose

Dose given

Date and time of administration

Route and method of administration

Ensures:

Validity of prescription

Signature of prescriber

The prescription is legible

Confirm height and weight of the child with parent or MAR

Identify and administer drugs due for administration correctly and safely

Explain to the child using age and developmentally appropriate language what medication is due and why

V3

Negotiate roles for the administration of the medication with the child and parent/carer

Provide positive reinforcement as appropriate during and following administration of medication

Omit drugs not to be administered and provides verbal rationale (ask candidate reason for non-administration if not verbalised)

Accurately record drug administration and non-administration

Evaluation Criteria

Clearly describe reason for initial admission and diagnosis

Record date of admission

Identify main nursing needs

Record approaches and interventions used

Outline current ability to self-care based on the person’s care plan

List areas identified for health education

Documents allergies

Ensure strike-through errors retain legibility

Print, sign and date

Appendices Tonsillectomy

9

Assessment Tonsillectomy

Page 1 of 1

Assume it is TODAY and it is 08:00. This documentation is for your use and is not marked by the examiners.

Scenario Sam Evans has arrived with a carer at the surgical ward to be admitted for an elective tonsillectomy. You are a children’s nurse working in the Surgical ward and have been asked to complete the nursing admission paperwork for Sam Evans.

Hospital Number 123456789

SAM EVANS MALE 01/01/2015 41 ALMOND CLOSE, TATTERELL, LL12 TBU

Test of Competence NHS Trust

Child Inpatient Admission/Discharge Form and Trust Core Patient Activities of Living

Initial Assessment

Ward: SURGICAL

Date of admission: TODAY Time: 07:00 Next of Kin details:

Consultant: MISS LEGUME Name:

Admitting nurse: Relationship:

Patient details: Address:

Name: SAM EVANS Post code:

Address: 41 ALMOND CLOSE, TATTERELL Mobile:

Post code: LL12 TBU GP details

Date of birth: 01/01/2015 Name: DR WILLIAMS

Height: 104 CM Address: TATTERELL GP SURGERY

Weight on admission: 17 KG Telephone: 01234 57890

Ethnicity: Post code: LL13 UCV

Religion: School/Nursery:

Special dietary needs: Yes No

If yes, please specify: Are immunisations up to date?

Language spoken by: Yes No

Child: Family:

Recent contact with infectious illnesses:

Permission to put child’s name on the board? Yes No

Yes No

Allergies (include medicines, latex, food, other): State reaction experienced:

Regular medications:

Where have you lived in the past 6 months: Parent resident?

Yes No

Temporary address (overseas patients): Who does the child live with:

Post code:

Hospital Number 123456789

SAM EVANS MALE 01/01/2015 41 ALMOND CLOSE, TATTERELL, LL12 TBU

Reason for admission: Past medical history:

Is this a re-admission:

Yes No

How many previous admissions in the last 12 months:

Additional professionals:

Health visitor:

Telephone number:

Significant social information: Social worker:

Telephone number:

Community nurse:

Telephone number:

Is the child in pain?

Yes No

Pain score:

Pain tool used:

Planning Care Tonsillectomy

Page 1 of 4

Candidate’s name _____________________________________________________ Note to Candidate: • Document to NMC standards • Your examiner will retain all documentation at the end of the station

Based on your nursing assessment of Sam Evans, please produce a nursing care plan for 2 relevant aspects of nursing and family-centred care suitable for Sam and their carer for the next 24 hours. Complete all sections of the care plan. Assume it is TODAY and it is 11:30.

Scenario Sam Evans arrived with a carer at the paediatric surgical ward this morning for an elective tonsillectomy. Sam has returned from recovery and is back on the paediatric surgical ward for further observation. Sam is accompanied by their carer.

of 4

Patient Details: Name: Sam Evans Hospital No: 123456789 Address: 41 Almond Close, Tatterell, LL12 TBU Date of Birth: 01/01/2015 1) Nursing problem / need

Aim(s) of care:

Re-evaluation date:

Care provided by nurse(s) Family-centred care activities

of 4

2) Nursing problem / need

Aim(s) of care:

Re-evaluation date:


NAME (Print): Nurse Signature: Date:

of 4

This page is not a required element but for use in case of error

3) Nursing problem / need

Aim(s) of care:

Re-evaluation date:


Implementing Care Tonsillectomy

Page 1 of 5

Candidate’s name _____________________________________________________ The examiner will retain all documentation at the end of the station

Please administer and document Sam’s 14:00 medications in a safe and professional manner. Note to Candidate: • Talk to the child and the carer • Please verbalise what you are doing and why • Read out the chart and explain what you are checking/giving/not giving and why • Complete all the required drug administration checks • Complete the documentation and use the correct codes • The correct codes are on the chart and on the drug trolley • Check and complete the last page of the chart • You have 15 minutes to complete this station, including the required documentation Complete all sections of the documentation Assume it is TODAY and it is 14:00.

Scenario Sam Evans was admitted to the paediatric surgical ward today for an elective tonsillectomy. Sam returned from recovery at 11.30. Sam has returned from recovery and is back on the paediatric surgical ward for further observation. Sam is accompanied by their carer.

Prescription Chart for: Sam Evans Male Date of birth: Hospital No: Address:

01/01/2015 123456789 41 Almond Close, Tatterell L12 TBU

Date and Time: TODAY 08:00

Page 2 of 5

Known Allergies or Sensitivities Type of Reaction PENICILLIN

ANAPHYLAXIS

Signature: Dr V Phillip 123 Date: TODAY

Information for Prescribers:

INFORMATION FOR NURSES ADMINISTERING MEDICATIONS:

USE BLOCK CAPITALS. RECORD TIME, DATE AND SIGN WHEN MEDICATION IS

ADMINISTERED OR OMITTED AND USE THE FOLLOWING CODES IF A MEDICATION IS NOT ADMINISTERED. SIGN AND DATE AND INCLUDE BLEEP

NUMBER.

SIGN AND DATE ALLERGIES BOX- IF NONE- WRITE "NONE KNOWN". 1. PATIENT NOT ON WARD

6. ILLEGIBLE/INCOMPLETE PRESCRIPTION, OR WRONGLY PRESCRIBED MEDICATION.

RECORD DETAILS OF ALLERGY. 2. OMITTED FOR A CLINICAL REASON 7.NIL BY MOUTH

DIFFERENT DOSES OF THE SAME MEDICATION MUST BE PRESCRIBED ON SEPARATE LINES.

3. MEDICINE IS NOT AVAILABLE 8. NO IV ACCESS

CANCEL BY PUTTING LINE ACROSS THE PRESCRIPTION AND SIGN AND DATE.

4. PATIENT REFUSED MEDICATION

9. OTHER REASON- PLEASE DOCUMENT

INDICATE START AND FINISH DATE. 5. NAUSEA OR VOMITING

* IF MEDICATIONS ARE NOT ADMINISTERED PLEASE DOCUMENT ON THE LAST PAGE OF THE DRUG CHART.

Does the patient have any documented Allergies?

YES NO

Please check the chart before administering medications.

WARD PAEDIATRIC SURGICAL WARD HEIGHT 3 FOOT 5 INCH (1.04m)

CONSULTANT MISS LEGUME WEIGHT 2.6 STONE (17 kg)

ANY Special Dietary requirements?

YES NO

If YES please specify N/A




Page 3 of 5


YES NO


ONCE ONLY AND STAT DOSES:

Date Time due Drug name Dose Route Prescriber

signature Bleep number Given by Time

given

TODAY 10:00 PARACETAMOL 255 mg PO Dr V Phillip 123 D MISTRY 10:15

PRN (AS REQUIRED MEDICATIONS):

Date Drug name Dose Route Instructions Prescriber signature

Bleep number

Given by

Time given

TODAY PARACETAMOL 255 mg PO 6 HOURLY PYREXIA Dr V Phillip 123

TODAY IBUPROFEN 85 mg PO 8 HOURLY PAIN Dr V Phillip 123

ANTIMICROBIALS:

1. DRUG PHENOXYMETHYLPENICILLIN

Date and Signature of Nurse Administering Medications. Code for non-administration.

DATE DOSE FREQUENCY ROUTE DURATION TIME TODAY

TODAY 125 mg 4 TIMES A DAY PO 5 DAYS 08:00 D MISTRY

Start date

14:00

Finish date

+4 DAYS 20:00

Prescriber signature and bleep number Dr V Phillip 123 00:00




Page 4 of 5


YES NO


REGULAR MEDICATION:

1. DRUG MOVICOL

Date and Signature of Nurse Administering Medications. Code for non-administration.

DATE DOSE FREQUENCY ROUTE DURATION TIME TODAY

TODAY 1 SACHET ONCE A DAY PO 5 DAYS 08:00 D MISTRY

Start date TODAY

Finish date +4 DAYS

Prescriber signature and bleep number Dr V Phillip 123

2. DRUG

Date and Signature of Nurse Administering Medications. Code for non-administration

DATE DOSE FREQUENCY ROUTE DURATION TIME

Start date

Finish date

Prescriber signature and bleep number

3. DRUG

Date and Signature of Nurse Administering Medications. Code for non-administration

DATE DOSE FREQUENCY ROUTE DURATION TIME

Start date

Finish date

Prescriber signature and bleep number




Page 5 of 5


YES NO


DRUGS NOT ADMINISTERED:

DATE TIME DRUG REASON NAME AND SIGNATURE

Evaluating Care Tonsillectomy

Page 1 of 3

Candidate’s Name: _________________________________________________ Note to Candidate: • This document must be completed using a BLUE PEN • At this station, you should have access to your Assessment, Planning and Implementation

documentation - If not, please ask the examiner for it - Please Note: there are 3 pages to this document

• Document to NMC standards • Your examiner will retain all documentation at the end of the station Scenario Sam Evans was admitted to the paediatric surgical ward today for an elective tonsillectomy. Sam returned from recovery and is now on the paediatric surgical ward for further observation. Sam is accompanied by their carer. Sam has received prescribed medications and is ready to be discharged.

Complete a transfer of care letter to ensure that the receiving health visitor has a full and accurate picture of Sam’s history and needs. Complete all sections of the documentation Assume it is TODAY and it is 16:30.


Page 2 of 3

Transfer of Care Letter

Patient Details: Name: Sam Evans Hospital No: 123456789 Address: 41 Almond Close, Tatterell, LL12 TBU Date of Birth: 01/01/2015 Clearly describe reason for admission.

Date of admission: Identify the main child/patient needs addressed during Sam’s stay.

Outline the nursing approaches and interventions provided to meet the identified needs.


Page 3 of 3

Outline Sam and their family’s current ability to self-care based on the child’s care plan.

Document Sam’s allergies and associated reactions.

List risks identified for Sam’s health education.

Date and time of transfer: NAME (Print): Nurse Signature: Date:

Amy

Oval

(To be used from 5 years until daybefore 12th birthday)PEWS is a tool to aid recognition of sick and deteriorating children.PEWS should be calculated every time observationsare recorded.

How to calculate score:

• Record observations at intervals as prescribed• Record observations in black pen with a dot• Score as per the colour key

0 1 3• Add total points scored• Record total score in PEWS box at bottom of chart• Action should be taken as below

Name .......................................................................

DOB .........................................................................

CHI ..........................................................................Affix Patient ID label

Ward................. Consultant .....................................

Chart Number ..................................................

Date .......................................................................

If observations are as expected for patient’s clinical condition, please note below accepted parameters for future callsAcceptable parameters HRRR BPO2 saturation

Doctor’s signature Date & Time

Upper acceptable

Normal range

Lower acceptable

Temperature °C

PAEDIATRIC SEPSIS 6Recognition: Suspected or proven

infection + 2 of:

• Core temperature < 36°C >38°C• Inappropriate Tachycardia• Altered mental state:

sleepy / irritable / floppy• Peripheral perfusion, CRT >2 sec,

cool, mottled

Lower threshold in vulnerable groups

Think could this be sepsis?IF NOT then why isthis child unwell?

If YES respond with Paediatric Sepsis 6 within 1 hour:

• Give high flow oxygen• IV or IO access and blood cultures, glucose,

lactate• Give IV or IO antibiotics• Consider fluid resuscitation• Consider inotropic support early• Involve senior clinicians/ specialists EARLY

Concerns include, but are not restricted to;

• gut feeling• looks unwell• apnoea• airway threat• increased work of breathing,• significant ↑ in O² requirement• Poor perfusion / blue / mottled

/ cool peripheries• seizures• confusion / irritability / altered

behaviour• hypoglycaemia• high pain score despite

appropriate analgesia

PEWS Level ofescalation Action to be taken

Regardless of PEWS always escalate if concerned about a patient's condition0 0

1-2 1

3-4or any in redzone

2

5 or more 3

Bradycardia, cardiac or respiratory arrest

PAEDIATRIC EARLYWARNING SCORE (PEWS)5 – 11 YEARS

Early WarningScore

1-2

3-4

5-6

7

Forth Valley Royal HospitalChildren’s Early Warning Score (CEWS) <1 Year

Name:

DOB:

CHI:

Address:

A CEWS should be calculated every time observations are recorded.


• Record observations as intervals as prescribed - Respiratory Rate, Heart Rate, Oxygen Saturation,Blood Pressure (please note on chart if Blood Pressure not carried out), Conscious Level (usingAVPU - A = alert, V = responds to voice, P = responds to pain) - please note patient may be asleep.

• Use colour key to work out the points scored for each section.

• Add points scored and record total CEWS score in box at bottom of CEWS chart.

• Action should be taken as described in the box below.

Action to be taken. Always use SBAR for communication.

Report to nurse in charge. Treat as prescribed. Repeat observations within 15 minutes,continue to observe. If no response to treatment inform junior doctor.

Report to nurse in charge and junior doctor. Review patient and clinical notes, treat asprescribed. Repeat observations within 15 minutes. If no response to treatment and / ongoing concern inform Registrar.

Request Registrar to attend urgently. Review patient and clinical notes, treat condition asrequired.

Place an emergency call 2222. Ask switch board to call the paediatric team and consultant ifrequired and when you want them.

Assessment of Acute Pain in Children

If observations are as expected for patient’s clinical condition,please note below accepted parameters for future calls

Acceptable ParametersHR RR BP O2 saturation

Doctor’s Name

Doctor’s Signature

Date and Time

Comments

Date commenced..............................................

This chart is number............................................ during this admission

Consultant.............................................................................................

0 1 2 3

Action taken must be documented in the E-ward (clinical notes if E-ward is not available).

No Pain Mild Pain Moderate Pain Severe PainFacesScale Score

Ladder Score 0 1-3 4-6 7-10

Behaviour * Normal activity* No movement* Happy

* Rubbing affectedarea

* Decreasedmovement

* Neutralexpression

* Able to play/talknormally

* Protective of affectedarea

* movement/quiet* Complaining of pain* Consolable crying* Grimaces when affected

part moved/touched

* No movement ordefensive of affected part

* Looking frightened* Very quiet* Restless/unsettled* Complaining of lots of

pain* Inconsolable crying

TF/1009/WCCS Review Date: 2014

Early WarningScore

1-2

3-4

5-6

7

Forth Valley Royal HospitalChildren’s Early Warning Score (CEWS) <1 Year

Name:

DOB:

CHI:

Address:

A CEWS should be calculated every time observations are recorded.


• Record observations as intervals as prescribed - Respiratory Rate, Heart Rate, Oxygen Saturation,Blood Pressure (please note on chart if Blood Pressure not carried out), Conscious Level (usingAVPU - A = alert, V = responds to voice, P = responds to pain) - please note patient may be asleep.

• Use colour key to work out the points scored for each section.

• Add points scored and record total CEWS score in box at bottom of CEWS chart.

• Action should be taken as described in the box below.

Action to be taken. Always use SBAR for communication.

Report to nurse in charge. Treat as prescribed. Repeat observations within 15 minutes,continue to observe. If no response to treatment inform junior doctor.

Report to nurse in charge and junior doctor. Review patient and clinical notes, treat asprescribed. Repeat observations within 15 minutes. If no response to treatment and / ongoing concern inform Registrar.

Request Registrar to attend urgently. Review patient and clinical notes, treat condition asrequired.

Place an emergency call 2222. Ask switch board to call the paediatric team and consultant ifrequired and when you want them.

Assessment of Acute Pain in Children

Eyes Open

BestVerbal

Response

BestMotor

Response

Eyes closedby swelling =

C

Endotrachealtubeor

tracheostomy= T

Usually recordthe best arm

response

Pupils

Right

Left

SizeReaction

SizeReaction

Reacts +No reaction -Eye closed c

Record right(R) and left (L)

separatelyif there is adifference

between thetwo sides

4

3

2

1

3

2

1

6

4

5

3

2

1

CO

MA

SCA

LESLIM

BM

OV

EMEN

T

AR

MS

LEGS

Time

Spontaneously

To Speech

To Pain

None

Alert, Coos andbabbles, words tousual ability

Irritable cries, lessthan normal ability

Cries in response to pain

Moans to pain

No response

Moves purposefully

and spontaneously

Withdraw to touch

Withdraws in

response to pain

Flexion to pain

Extension to pain

None

Score

Normal power

Mild weakness

Severe weakness

Spastic flexion

Extension

No response

Normal power

Mild weakness

Severe weakness

Extension

No response

Pupil Scale (m.m.)

8 7 6 5 4 3 2 1

4

5

If observations are as expected for patient’s clinical condition,please note below accepted parameters for future calls

Acceptable ParametersHR RR BP O2 saturation

Doctor’s Name

Doctor’s Signature

Date and Time

Comments

Date commenced..............................................

This chart is number............................................ during this admission

Consultant.............................................................................................

0 1 2 3

Action taken must be documented in the E-ward (clinical notes if E-ward is not available).

Neurological Observations Developed by Healthcare Improvement Scotland

SAM EVANS

01/01/2015

123456789

SAU MISS TRUNCHBULL

Staff or Carer Concerns(Staff = S, Carer = C, None = N)

Pain ScoreBlood Glucose

Pain ScoreBlood Glucose

0

4.6

5-11YEARS

0

1

3

PEWSPEWS 6

InitialsInitialsTime of medical review

if score elevatedTime of medical review

if score elevated

NAME: CHI NO:

Date:

Time:

Location

Prescribed frequency of observations:

0800

15 min

Temperature oC

40393837363534

actual 36.8

•

40393837363534actual

Temp oC

•

92

4L

94+

92 - 93

less than 92

actual

less than 2 secs2 - 4 secs

more than 4 secs

70

60

50

40

30

20

10

0actual

•

35

146

•

170160150140130120110100908070605040

actual

17016015014013012011010090807060

actual

Blood Pressure(Plot systolic and

diastolic but scoreSYSTOLIC only)

BP cuff size:

100/60less than 2 secs2 - 4 secsmore than 4 secs

CRT

BP

O2

SpO2

RR

170160150140130120110100908070605040actual

HR

70

60

50

40

30

20

10

0actual

exam

ple

exam

ple

Capillary return(central in seconds)

SpO2

Oxygenair

l/minMode of Delivery eg facemask, nasal cannulae

Respiratory Rate

Heart Rate

94+

92 - 93

less than 92

actual

airl/minMode of Delivery

AlertAsleepVerbal

PainUnresponsive

• AlertAsleepVerbalPainUnresponsive

AVPU(if V / P / U complete

GCS chart)

Conscious level(if V / P / U

complete GCS chart)

exam

ple

FM

C (Staff= S, Carer = C,None = N)

17016015014013012011010090807060actual

Ward

ABC

08.15

SAM EVANS 123456789